Patient selection to enhance the long-term benefit of first generation drug-eluting stents for coronary revascularisation procedures. Insights from a large multicentre registry

First-generation sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES) have dramatically reduced restenosis, although concern still exists about the long-term safety of this technology since observational studies have shown a steady increase in the rate of late stent thrombosis (LST), an infrequent but catastrophic complication. Although the mechanisms of LST are multifactorial, our laboratory has demonstrated that delayed arterial healing accompanied by poor endothelialisation is the primary pathogical substrate underlying this event. Delayed arterial healing is associated with penetration of necrotic core, long/overlapping stents and bifurcation stenting, especially in flow divider (high shear) regions. Grade V stent fracture is also associated with adverse pathogical findings including LST and restenosis. Moreover, localised hypersensitivity reaction is exclusive to SES as an underlying mechanism of LST, while malapposition secondary to excessive fibrin deposition is associated with PES. Uncovered struts are still identified in both SES and PES with implant duration beyond 12 months, particularly in stents placed for ‘off-label’ indications. In conclusion, the first generation of drug-eluting stents (DES) certainly reduce neointimal growth but this comes at the price of delayed healing.

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Pathology of First-generation Drug-eluting Stents in Humans

Interventional Cardiology Review ◽

10.15420/icr.2011.6.1.28 ◽

2011 ◽

Vol 6 (1) ◽

pp. 28

Author(s):

Fumiyuki Otsuka ◽

Masataka Nakano ◽

Saami K Yazdani ◽

Elena Ladich ◽

Frank D Kolodgie ◽

...

Keyword(s):

First Generation ◽

Underlying Mechanism ◽

Drug Eluting Stents ◽

Steady Increase ◽

Stent Fracture ◽

Late Stent Thrombosis ◽

Flow Divider ◽

Bifurcation Stenting ◽

Drug Eluting

First-generation sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES) have dramatically reduced restenosis, although concern still exists about the long-term safety of this technology since observational studies have shown a steady increase in the rate of late stent thrombosis (LST), an infrequent but catastrophic complication. Although the mechanisms of LST are multifactorial, our laboratory has demonstrated that delayed arterial healing accompanied by poor endothelialisation is the primary pathogical substrate underlying this event. Delayed arterial healing is associated with penetration of necrotic core, long/overlapping stents and bifurcation stenting, especially in flow divider (high shear) regions. Grade V stent fracture is also associated with adverse pathogical findings including LST and restenosis. Moreover, localised hypersensitivity reaction is exclusive to SES as an underlying mechanism of LST, while malapposition secondary to excessive fibrin deposition is associated with PES. Uncovered struts are still identified in both SES and PES with implant duration beyond 12 months, particularly in stents placed for ‘off-label’ indications. In conclusion, the first generation of drug-eluting stents (DES) certainly reduce neointimal growth but this comes at the price of delayed healing.

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TCT-198 Comparing Long-term Outcomes of First-Generation and Second-Generation Drug Eluting Stents in Patients with Coronary Artery Disease

Journal of the American College of Cardiology ◽

10.1016/j.jacc.2018.08.1316 ◽

2018 ◽

Vol 72 (13) ◽

pp. B84

Author(s):

Parth Parikh ◽

Kinjal Banerjee ◽

Amar Krishnaswamy ◽

ravi nair ◽

Russell Raymond ◽

...

Keyword(s):

Coronary Artery Disease ◽

Coronary Artery ◽

First Generation ◽

Second Generation ◽

Drug Eluting Stents ◽

Long Term Outcomes ◽

Drug Eluting ◽

Artery Disease

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Incomplete Revascularization is Associated With Greater Risk of Long-Term Mortality After Stenting in the Era of First Generation Drug-Eluting Stents

The American Journal of Cardiology ◽

10.1016/j.amjcard.2013.05.003 ◽

2013 ◽

Vol 112 (6) ◽

pp. 775-781 ◽

Cited By ~ 13

Author(s):

Chuntao Wu ◽

Anne-Marie Dyer ◽

Gary Walford ◽

David R. Holmes ◽

Spencer B. King ◽

...

Keyword(s):

First Generation ◽

Drug Eluting Stents ◽

Incomplete Revascularization ◽

Drug Eluting ◽

Long Term Mortality

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Premature Discontinuation of Dual Antiplatelet Therapy After Coronary Stenting in Veterans: Characteristics and Long‐Term Outcomes

Journal of the American Heart Association ◽

10.1161/jaha.120.018481 ◽

2021 ◽

Author(s):

Scott Kinlay ◽

Lien Quach ◽

Jean Cormack ◽

Natalie Morgenstern ◽

Ying Hou ◽

...

Keyword(s):

Percutaneous Coronary Intervention ◽

First Generation ◽

Second Generation ◽

Dual Antiplatelet Therapy ◽

Coronary Intervention ◽

Adverse Outcomes ◽

Drug Eluting Stents ◽

Percutaneous Coronary ◽

Drug Eluting

Background Premature discontinuation of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention is related to higher short‐term risks of adverse outcomes. Whether these risks persist in the long‐term is uncertain. Methods and Results We assessed all patients having percutaneous coronary intervention with coronary second‐ or first‐generation drug‐eluting stents in the Veterans Affairs healthcare system between 2006 and 2012 who were free of major ischemic or bleeding events in the first 12 months. The characteristics of patients who stopped DAPT prematurely (1–9 months duration), compared with >9 to 12 months, or extended duration (>12 months) were assessed by odds ratios (ORs) from multivariable logistic models. The risk of adverse clinical outcomes over a mean 5.1 years in patients who stopped DAPT prematurely was assessed by hazard ratios (HRs) and 95% CIs from Cox regression models. A total of 14 239 had second‐generation drug‐eluting stents, and 8583 had first‐generation drug‐eluting stents. Premature discontinuation of DAPT was more likely in Black patients (OR, 1.54; 95% CI, 1.40–1.68), patients with greater frailty (OR, 1.04; 95% CI, 1.03–1.05), and patients with higher low‐density lipoprotein cholesterol, and less likely in patients on statins (OR, 0.87; 95% CI, 0.80–0.95). Patients who stopped DAPT prematurely had higher long‐term risks of death (second‐generation drug‐eluting stents: HR, 1.35; 95% CI, 1.19–1.56), myocardial infarction (second‐generation drug‐eluting stents: HR, 1.46; 95% CI, 1.22–1.74), and repeated coronary revascularization (second‐generation drug‐eluting stents: HR, 1.24; 95% CI, 1.08–1.41). Conclusions Patients who stop DAPT prematurely have features that reflect greater frailty, poorer medication use, and other social factors. They continue to have higher risks of major adverse outcomes over the long‐term and may require more intensive surveillance many years after percutaneous coronary intervention.

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